Chronic heart failure nice guidelines

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Chronic heart failure nice guidelines

  1. 1. NHS National Institute for Clinical ExcellenceChronic heart failureManagement of chronic heart failure inadults in primary and secondary careClinical Guideline 5July 2003Developed by the NationalCollaborating Centre for Chronic Conditions
  2. 2. Clinical Guideline 5 Chronic heart failure Management of chronic heart failure in adults in primary and secondary care Issue date: July 2003 To order copies Copies of this guideline can be ordered from the NHS Response Line; telephone 0870 1555 455 and quote reference number N0247. A version for people who want to understand what NICE has told the NHS, called Management of Heart Failure. Understanding NICE Guidance – Information for People with Heart Failure, Their Carers, and the Public, is also available from the Response Line; quote reference number N0248 for an English only version and N0249 for an English and Welsh version.This document has been circulated to the following:• PCT Chief Executives• NHS Trust Chief Executives in England and Wales• Local Health Board General Managers• Strategic Health Authority Chief Executives in England and Wales• Medical and Nursing Directors in England and Wales• Clinical Governance Leads in England and Wales• Audit Leads in England and Wales• NHS Trust, PCT and LHB libraries in England and Wales• NHS Director Wales• Chief Executive of the NHS in England• Directors of Directorates of Health and Social Care in England and Wales• Special Health Authority Chief Executives• Community Health Councils in England and Wales• Patient Advocacy Groups• Commission for Health Improvement• NHS Clinical Governance Support Team• Chief Medical Officers, Nursing Officers and Pharmaceutical Officers in England and Wales• Medical Director & Head of NHS Quality - Welsh Assembly Government• Practice Nurses in England and Wales• GP partners in England and Wales• Chief Pharmacists, Heads of Drug Purchasing, Heads of Drug Information, GP Prescribing Advisors and Purchase Advisors in England and Wales• Consultant Cardiologists in England and Wales• Representative bodies for health services, professional organisations and statutory bodies, Royal Colleges This guidance is written in the following context: This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Health professionals are expected to take it fully into account when exercising their clinical judgment The guidance does not, however, override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.National Institute forClinical ExcellenceMidCity Place71 High HolbornLondonWC1V 6NAWeb: www.nice.org.ukISBN: 1-84257-323-3Published by the National Institute for Clinical ExcellenceJuly 2003Typeset by Icon DesignPrinted by Abba Litho Sales Limited, London© Copyright National Institute for Clinical Excellence, July 2003. All rights reserved. This material may be freelyreproduced for educational and not-for-profit purposes within the NHS. No reproduction by or for commercialorganisations is allowed without the express written permission of the National Institute for Clinical Excellence.
  3. 3. ContentsHeart failure 2Key recommendations 31 Guidance 4 1.1 Diagnosing heart failure 4 1.2 Treating heart failure 7 1.3 Monitoring 17 1.4 Referral and approach to care 19 1.5 Supporting patients and carers 20 1.6 Anxiety and depression 22 1.7 End of life issues 222 Notes on the scope of the guidance 233 Implementation in the NHS 24 3.1 In general 24 3.2 Audit 244 Research recommendations 245 Full guideline 246 Related NICE guidance 257 Review date 25Appendix A: Grading scheme 26Appendix B: The Guideline Development Group 27Appendix C: The Guideline Review Panel 30Appendix D: Further information on pharmacological treatment 31Appendix E: Technical detail on the criteria for audit 38
  4. 4. Heart failure Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The syndrome of heart failure is characterised by symptoms such as breathlessness and fatigue, and signs such as fluid retention. This guideline offers best practice advice on the care of adult patients (aged 18 years or older) who have symptoms or a diagnosis of chronic heart failure. It aims to define the most effective combination of symptoms, signs and investigations required to establish a diagnosis of heart failure, and those which will influence therapy or provide important prognostic information. It also gives guidance on the treatment, monitoring and support of patients with heart failure.2 NICE Guideline – Chronic heart failure
  5. 5. Key recommendationsThe following recommendations have been identified as prioritiesfor implementation.Diagnosis1 The basis for historical diagnoses of heart failure should be reviewed, and only patients whose diagnosis is confirmed should be managed in accordance with this guideline.2 Doppler 2D echocardiographic examination should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle and detect intracardiac shunts.Treatment3 All patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor.4 Beta blockers licensed for use in heart failure should be initiated in patients with heart failure due to left ventricular systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist).Monitoring5 All patients with chronic heart failure require monitoring. This monitoring should include: • a clinical assessment of functional capacity, fluid status, cardiac rhythm, and cognitive and nutritional status • a review of medication, including need for changes and possible side effects • serum urea, electrolytes and creatinine.Discharge6 Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised.7 The primary care team, patient and carer must be aware of the management plan.Supporting patients and carers8 Management of heart failure should be seen as a shared responsibility between patient and healthcare professional. NICE Guideline – Chronic heart failure 3
  6. 6. The following guidance is evidence based. The grading scheme used for the recommendations (A, B, C, Good Practice Point [GPP], NICE) is described in Appendix A; a summary of the evidence on which the guidance is based is provided in the full guideline (see Section 5). 1 Guidance 1.1 Diagnosing heart failure The full evaluation of heart failure is more than stating whether the syndrome is present or not; it requires consideration of the underlying abnormality of the heart, the severity of the syndrome, the aetiology, precipitating and exacerbating factors, identification of concomitant disease relevant to the management, and an estimation of prognosis. It is important to exclude other conditions that may masquerade as heart failure (see Table 1). The recommendations for diagnosing heart failure are summarised in an algorithm (Figure 1) on page 5. Table 1 Conditions presenting with similar symptoms Other conditions that may present with similar symptoms • Obesity • Hypoalbuminaemia • Chest disease – including • Intrinsic renal or hepatic lung, diaphragm or chest wall disease • Venous insufficiency in lower • Pulmonary embolic disease limbs • Depression and/or anxiety • Drug-induced ankle swelling disorders (e.g. dihydropyridine calcium channel blockers) • Severe anaemia or thyroid disease • Drug-induced fluid retention (e.g. NSAIDs) • Bilateral renal artery stenosis 1.1.1 Cardiac assessment 1.1.1.1 Take a careful and detailed history, and perform a clinical GPP examination. These should be combined with tests to confirm the presence of heart failure and make a complete diagnosis.4 NICE Guideline – Chronic heart failure
  7. 7. Figure 1 Algorithm summarising recommendations for the diagnosisof heart failure Suspected heart failure because of history, symptoms, and signs Other recommended tests: Seek to exclude heart failure (mostly to exclude other through: conditions) • 12-lead ECG Chest X-ray • and/or natriuretic peptides Blood tests: U&Es, creatinine, FBC, (BNP or NTproBNP) – where TFTs, LFTs, glucose, and lipids available Urinalysis, peak flow or spirometry Both normal – One or more abnormal heart failure unlikely consider alternative diagnosis Imaging by echocardiography* No abnormality detected Abnormal Heart failure unlikely, but if Assess heart failure severity, diagnostic doubt persists consider aetiology, precipitating and diastolic dysfunction and consider exacerbating factors and type of referral for specialist assessment cardiac dysfunction Correctable causes must be identified Consider referral* Alternative methods of imaging the heart should be considered when a poor image isproduced by transthoracic Doppler 2D echocardiography – alternatives includetransoesophageal Doppler 2D echocardiography, radionuclide imaging or cardiac magneticresonance imagingKey:BNP B-type natriuretic peptideECG ElectrocardiogramFBC Full blood countLFTs Liver function testsNTproBNP N-terminal pro-B-type natriuretic peptideTFTs Thyroid function testsU&Es Urea and electrolytes NICE Guideline – Chronic heart failure 5
  8. 8. 1.1.1.2 Healthcare professionals should seek to exclude a diagnosis B of heart failure through the following investigations: • 12-lead ECG • and/or natriuretic peptides (BNP or NTproBNP) – where available. If one or both are abnormal, a diagnosis of heart failure cannot be excluded and transthoracic Doppler 2D echocardiography should be performed because it consolidates the diagnosis and provides information on the underlying functional abnormality of the heart. 1.1.1.3 Efforts should be made to exclude other disorders that may GPP present in a similar manner. 1.1.1.4 To evaluate possible aggravating factors and/or alternative GPP diagnoses the following tests are recommended. • Chest X-ray • Blood tests: - biochemical profile including electrolytes, urea and creatinine - full blood count - thyroid function tests - liver function tests - fasting lipids - fasting glucose • Urinalysis • Peak flow or spirometry 1.1.1.5 Transthoracic Doppler 2D echocardiographic examination GPP should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts. 1.1.1.6 Transthoracic Doppler 2D echocardiographic studies should GPP be performed on high-resolution equipment, by experienced operators trained to the relevant professional standards. Need and demand for these studies should not compromise quality. 1.1.1.7 The reporting of echocardiography should be by those GPP experienced in doing so.6 NICE Guideline – Chronic heart failure
  9. 9. 1.1.1.8 Alternative methods of imaging the heart should be B considered when a poor image is produced by echocardiography. Such methods may include radionuclide angiography, cardiac magnetic resonance imaging, or transoesophageal Doppler 2D echocardiography.1.1.2 Diastolic heart failure1.1.2.1 Where the diagnosis is unclear, or if a diagnosis of diastolic GPP heart failure is being considered, the patient should be referred for more specialist assessment.1.1.3 Review of existing diagnoses1.1.3.1 The basis for historical diagnoses of heart failure should be GPP reviewed, and only patients whose diagnosis is confirmed should be managed in accordance with this guideline.1.1.3.2 If the diagnosis of heart failure is still suspected, but GPP confirmation of the underlying cardiac abnormality has not occurred, then the patient should have appropriate further investigation.1.2 Treating heart failureTreatments are available that can improve the life expectancy andquality of life of a person with heart failure. Treatmentrecommendations are given below, and include aspects of lifestyle,pharmacological therapy, and invasive procedures. It is also helpful toconsider the need to keep patients fully informed about theircondition and the treatment options, and this is reflected in therecommendations.1.2.1 LifestyleExercise training and rehabilitation1.2.1.1 Patients with heart failure should be encouraged to adopt B regular aerobic and/or resistive exercise. This may be more effective when part of an exercise programme or a programme of rehabilitation. NICE Guideline – Chronic heart failure 7
  10. 10. Smoking 1.2.1.2 Patients must be strongly advised not to smoke. Referral to GPP smoking cessation services should be considered. Alcohol 1.2.1.3 Patients with alcohol-related heart failure should abstain C from drinking alcohol. 1.2.1.4 Healthcare professionals should discuss alcohol consumption GPP with the patient and tailor their advice appropriately to the clinical circumstances. Sexual activity 1.2.1.5 Healthcare professionals should be prepared to broach GPP sensitive issues with patients, such as sexual activity, as these are unlikely to be raised by the patient. Vaccination 1.2.1.6 Patients with heart failure should be offered an annual GPP vaccination against influenza. 1.2.1.7 Patients with heart failure should be offered vaccination GPP against pneumococcal disease (only required once). Air travel 1.2.1.8 Air travel will be possible for the majority of patients with GPP heart failure, depending on their clinical condition at the time of travel. Driving regulations 1.2.1.9 Heavy Goods Vehicle and Public Service Vehicle licence: GPP physicians should be up to date with the latest Driver and Vehicle Licensing Authority guidelines. Check the website for regular updates: www.dvla.gov.uk/8 NICE Guideline – Chronic heart failure
  11. 11. 1.2.2 Pharmacological therapy for patients with heart failure due to left ventricular systolic dysfunction.Drug therapy is required for the vast majority of patients with heartfailure. It is the responsibility of the individual prescriber to check thedosage of medication. This document should be read as a guide totreatment rather than being considered a protocol that must befollowed prescriptively in all patients. Treatment should be tailored tothe individual patient, with referral for more specialist advice beingconsidered where appropriate.Note that at the time of issue of this guideline, the following drugsin this guideline are unlicensed in the UK for the treatment of heartfailure or its common signs or symptoms.• angiotensin II receptor antagonists• the positive inotropic agent dobutamine• calcium channel blockers.Recommendations on specific drugsRecommendations for pharmacological therapy for patients withheart failure due to left ventricular systolic dysfunction aresummarised in the algorithm on page 10.Diuretics1.2.2.1 Diuretics (see Appendix D, Table A) should be routinely used C for the relief of congestive symptoms and fluid retention in patients with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure therapies.Angiotensin converting enzyme (ACE) inhibitors1.2.2.2 All patients with heart failure due to left ventricular systolic A dysfunction should be considered for treatment with an ACE inhibitor (see Appendix D, Table B).1.2.2.3 ACE inhibitor therapy should be instituted in patients with A heart failure due to left ventricular systolic dysfunction before beta-blockade is introduced.1.2.2.4 ACE inhibitor therapy should be initiated at the appropriate GPP dose (see Appendix D, Table B), and titrated upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. NICE Guideline – Chronic heart failure 9
  12. 12. Figure 2 Algorithm for the pharmacological treatment of symptomatic heart failure due to left ventricular systolic dysfunction Patients with symptomatic heart failure due to left ventricular systolic dysfunction should be treated with the following drugs (if tolerated and not contraindicated) and in the sequence indicated. The reader must refer to the text of the guideline for more detailed discussion and explanation. Please note: • Diuretic is first-line therapy when a patient presents with acute pulmonary oedema • Please refer to Appendix D for starting doses of drugs • The arrow on the left-hand margin indicates the increasing likelihood of the need for specialist input. Generalist New diagnosis Or if ACE inhibitor not { Start ACE tolerated (e.g. due to Add diuretic inhibitor severe cough) Diuretic therapy is and titrate Consider angiotensin II likely to be required upwards receptor antagonist to control congestive symptoms and fluid retention Add beta- Specialist input Add digoxin blocker and If a patient in sinus titrate rhythm remains upwards symptomatic despite therapy with a diuretic, ACE inhibitor (or angiotensin II Add spironolactone receptor If patient remains antagonist) and moderately to beta-blocker severely symptomatic or if patient is in despite optimal drug atrial fibrillation therapy listed above then use as first-line therapy (see page 11) Seek specialist advice for further options Specialist10 NICE Guideline – Chronic heart failure
  13. 13. 1.2.2.5 Blood biochemistry (urea, creatinine and electrolytes) should GPP be measured after initiation and at each dose increment.Beta-blockers1.2.2.6 Beta-blockers licensed for use in heart failure should be A initiated in patients with heart failure due to left ventricular systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist). See Appendix D, Table C.1.2.2.7 Beta-blockade therapy for heart failure should be introduced C in a ‘start low, go slow’ manner, with assessment of heart rate, blood pressure, and clinical status after each titration.1.2.2.8 Patients who develop heart failure due to left ventricular GPP systolic dysfunction and who are already on treatment with a beta-blocker for a concomitant condition (for example, angina, hypertension) should continue with a beta-blocker – either their current beta-blocker or an alternative licensed for heart failure treatment.Aldosterone antagonists1.2.2.9 Patients with heart failure due to left ventricular systolic A dysfunction who remain moderately to severely symptomatic despite optimal therapy (as outlined in the algorithm) should be prescribed spironolactone at a dose of 12.5 to 50 mg once per day (see Appendix D, Table D) – specialist advice should be sought.1.2.2.10 Patients with heart failure taking spironolactone should have GPP blood potassium and creatinine levels monitored for signs of hyperkalaemia and/or deteriorating renal function.* If hyperkalaemia is a problem then the dose of spironolactone should be halved and biochemistry rechecked. *See Section 1.3, page 17 for further detailsDigoxin1.2.2.11 Digoxin is recommended for: • worsening or severe heart failure due to left ventricular A systolic dysfunction despite ACE inhibitor, beta-blocker and diuretic therapy • patients with atrial fibrillation and any degree of heart C failure. NICE Guideline – Chronic heart failure 11
  14. 14. Angiotensin II receptor antagonists 1.2.2.12 At the time of issue of this guideline, angiotensin II receptor A antagonists (Appendix D, Table E) are not licensed in the UK for heart failure and studies are ongoing. However, angiotensin II receptor antagonists may provide an alternative to ACE inhibitors for patients intolerant of ACE inhibitors (for example, because of cough). 1.2.2.13 The triple combination of ACE inhibitor, beta-blocker and GPP angiotensin II receptor antagonist should be avoided, pending the results of further trials. Amiodarone 1.2.2.14 The decision to prescribe amiodarone should be made in GPP consultation with a specialist. 1.2.2.15 The need to continue the prescription should be reviewed GPP regularly. 1.2.2.16 Patients taking amiodarone should have a routine 6-monthly GPP clinical review, including liver and thyroid function test, and including a review of side effects. Anticoagulants 1.2.2.17 Anticoagulation is indicated for patients with the A combination of heart failure and atrial fibrillation (see also page 16). 1.2.2.18 In patients with heart failure in sinus rhythm, anticoagulation GPP should be considered for those with a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus. Aspirin 1.2.2.19 Aspirin (75–150 mg once daily) should be prescribed for B patients with the combination of heart failure and atherosclerotic arterial disease (including coronary heart disease). Statins (hydroxymethylglutaryl-coenzyme A reductase inhibitors) 1.2.2.20 Patients with the combination of heart failure and known GPP atherosclerotic vascular disease should receive statins only in accordance with current indications. Specific trials in this area are ongoing.12 NICE Guideline – Chronic heart failure
  15. 15. Isosorbide/hydralazine combination (specialist initiation only)1.2.2.21 An isosorbide/hydralazine combination may be used in A patients with heart failure who are intolerant of ACE inhibitors or angiotensin II receptor antagonists.Inotropic agents (specialist use only)1.2.2.22 Intravenous inotropic agents (such as dobutamine, milrinone A or enoximone) should only be considered for the short-term treatment of acute decompensation of chronic heart failure. This will require specialist advice.Calcium channel blockers1.2.2.23 Amlodipine should be considered for the treatment of A co-morbid hypertension and/or angina in patients with heart failure, but verapamil, diltiazem or short-acting dihydropyridine agents should be avoided.Major co-morbidities that impact on the pharmacologicalmanagement of heart failureThe presence of certain co-morbidities may affect the drugs that canbe used for the treatment of heart failure, or increase the likelihoodof side effects. The major co-morbidities that impact on themanagement of heart failure are summarised in Appendix D, Table F.Side effects of drugs commonly used in the treatment of heart failureAll drugs have side effects. See the Summary of Product Characteristicsfor individual drugs for details.Improving adherence to pharmacological therapy1.2.2.24 Dosing regimens should be kept as simple as possible, and B the healthcare professional should ensure that the patient and carer are fully informed about their medication. NICE Guideline – Chronic heart failure 13
  16. 16. 1.2.3 Invasive procedures Although drug therapy is the mainstay of treatment of heart failure, some patients will also benefit from diagnostic or interventional invasive procedures. These procedures are normally organised by a specialist. This guideline can only give general advice, and specialist advice is strongly recommended where such procedures might be considered. Coronary revascularisation 1.2.3.1 Coronary revascularisation should not be routinely considered C in patients with heart failure due to systolic left ventricular impairment, unless they have refractory angina. Cardiac transplantation 1.2.3.2 Specialist referral for transplantation should be considered in C patients with severe refractory symptoms or refractory cardiogenic shock. Cardiac resynchronisation therapy 1.2.3.3 Resynchronisation therapy should be considered in selected A patients with left ventricular systolic dysfunction (left ventricular ejection fraction ≤ 35%), drug refractory symptoms, and a QRS duration > 120 ms. The results of ongoing trials will help guide appropriate patient selection. Implantable cardioverter-defibrillators (ICDs) 1.2.3.4 Recommendation from NICE Technology Appraisal Guidance NICE No. 11, Guidance on the use of implantable cardioverter 2000 defibrillators for arrhythmias (see Section 6, page 25). The use of implantable cardioverter defibrillators (ICDs) should be routinely considered for patients in the following categories: 1. Secondary prevention, that is for patients who present, in the absence of a treatable cause, with: • cardiac arrest due to either ventricular tachycardia (VT) or ventricular fibrillation • spontaneous sustained VT causing syncope or significant haemodynamic compromise • sustained VT without syncope/cardiac arrest, and who have an associated reduction in ejection fraction (less than 35%) but are no worse than Class III* of the New York Heart Association functional classification of heart failure.14 NICE Guideline – Chronic heart failure
  17. 17. 2. ‘Primary prevention’ for patients with: • a history of previous myocardial infarction and all of the following: i) non-sustained VT on Holter (24-hour ECG) monitoring ii) inducible VT on electrophysiological testing iii) left ventricular dysfunction with an ejection fraction less than 35% and no worse than Class III* of the New York Heart Association functional classification of heart failure. • A familial cardiac condition with a high risk of sudden death, including long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome, arrhythmogenic right ventricular dysplasia and following repair of tetralogy of Fallot. *Marked limitation of physical activity. Although patients are comfortable at rest, less than ordinary physical activity will lead to symptoms (symptomatically ‘moderate’ heart failure)1.2.4 Oxygen therapy and continuous airway pressureThe evidence for oxygen therapy and continuous positive airwaypressure was considered during development of this guideline, but itwas not possible to make specific recommendations because of thesmall evidence base. For further details, see the full guideline (seeSection 5).1.2.5 Recommendations for treatment of heart failure not due to left ventricular systolic dysfunctionValve disease C1.2.5.1 Patients with heart failure due to valve disease should be referred for specialist assessment and advice regarding follow-up. C1.2.5.2 ACE inhibitor therapy should not be initiated in a patient with a clinical suspicion of haemodynamically significant valve disease, until the valve disease has been assessed by a specialist. NICE Guideline – Chronic heart failure 15
  18. 18. Diastolic dysfunction 1.2.5.3 The diagnosis and treatment of diastolic dysfunction should GPP be made by a specialist, and other conditions that present in a similar way may need to be considered. Patients in whom this diagnosis has been made should usually be treated with a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). Patients who do not respond to this treatment will require further specialist advice. Other causes The management of other causes of heart failure requires specialist input. This would include congenital heart disease, cardiomyopathies, and specific heart muscle disease such as amyloid. 1.2.6 Recommendations for patients with heart failure and atrial fibrillation 1.2.6.1 For patients with heart failure and atrial fibrillation, C specialist advice should be sought as to whether the aim is improvement of heart rate control or cardioversion (return to sinus rhythm). 1.2.6.2 Anticoagulation is indicated for patients with heart failure A and atrial fibrillation (see also anticoagulation section, page 12). 1.2.7 Recommendations for different subgroups of patients with heart failure Age 1.2.7.1 The management of heart failure should be determined by A clinical criteria, irrespective of the age of the patient. 1.2.7.2 Tolerance of drugs may be lower and side effects require GPP closer and more frequent monitoring in older patients. Gender 1.2.7.3 The principles of pharmacological management of heart GPP failure should be the same for men and women. 1.2.7.4 The potential teratogenic effects of drugs should be GPP considered.16 NICE Guideline – Chronic heart failure
  19. 19. Pregnancy1.2.7.5 In women of reproductive age who have heart failure, GPP contraception and pregnancy should be discussed. If pregnancy is being considered or occurs, specialist advice should be sought. Subsequently, specialist care should be shared between the cardiologist and obstetrician.Ethnicity1.2.7.6 The principles of pharmacological management should be GPP the same for all patients with heart failure, regardless of ethnicity.1.3 MonitoringThe clinical condition of a person with heart failure may fluctuateand repeated admission to hospital is common, particularly forpatients with more severe heart failure. Monitoring of clinical statusis necessary and will involve healthcare professionals in both primaryand secondary care. Patients and their carers are playing anincreasing role in monitoring, but this requires appropriate educationand support.1.3.1 Clinical review1.3.1.1 All patients with chronic heart failure require monitoring. GPP This monitoring should include (see Table 2, page 18): • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status • a review of medication, including need for changes and possible side effects • serum urea, electrolytes and creatinine *. * This is a minimum. Patients with co-morbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or spironolactone.1.3.1.2 More detailed monitoring will be required if the patient has GPP significant co-morbidity or has deteriorated since the previous review.1.3.1.3 The frequency of monitoring should depend on the clinical GPP status and stability of the patient. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is required at least 6 monthly for stable patients with proven heart failure. NNICE Guideline – Chronic heart failure 17
  20. 20. 1.3.1.4 Patients who wish to be involved in monitoring of their GPP condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidelines as to what to do in the event of deterioration. 1.3.2 Therapeutic drug monitoring of serum digoxin concentrations 1.3.2.1 Routine monitoring of serum digoxin concentrations is not GPP recommended. A digoxin concentration measured within 8–12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-compliance. 1.3.2.2 The serum digoxin concentration should be interpreted in GPP the clinical context as toxicity may occur even when the concentration is within the ‘therapeutic range’. Table 2 Assessments to be made at clinical review Assessment of Chiefly from history, but more objectively functional capacity by use of New York Heart Association class, specific quality-of-life questionnaires, 6-minute walk test, or maximal exercise test. Note: not all of these tests are likely to be necessary, or appropriate, at each assessment. Assessment of fluid Chiefly by physical examination – changes status in body weight, extent of jugular venous distension, lung crackles and hepatomegaly, extent of peripheral oedema, and lying and standing blood pressure (postural drop in blood pressure may indicate hypovolaemia) Assessment of Chiefly by clinical examination, but may cardiac rhythm require 12-lead electrocardiogram (ECG) or 24-hour electrocardiographic (‘Holter’) monitoring if suspicion of arrhythmia Laboratory assessment Checking of serum biochemistry (urea, electrolytes, creatinine) is essential, but other tests (such as thyroid function, haematology, liver function, level of anticoagulation) may also be required depending on the medication prescribed and co-morbidity18 NICE Guideline – Chronic heart failure
  21. 21. 1.4 Referral and approach to careThe management of heart failure is likely to be shared betweenhealthcare professionals in both primary and secondary care. Patientsand their carers are increasingly involved in management decisions.Work with patient focus groups suggests that the major failings ofmanagement relate to poor communication between healthcareprofessionals, and between patients and the professionals caring forthem.1.4.1 Referral for more specialist advice1.4.1.1 Patients with heart failure require specialist advice in the GPP following situations. • Heart failure due to valve disease, diastolic dysfunction or any other cause except left ventricular systolic dysfunction. • One or more of the co-morbidities outlined in Appendix D, Table F. • Angina, atrial fibrillation or other symptomatic arrhythmia. • Women who are planning a pregnancy or who are pregnant.1.4.1.2 The following situations also require referral. GPP • Severe heart failure. • Heart failure that does not respond to treatment as discussed in this guideline and outlined in the algorithm. • Heart failure that can no longer be managed effectively in the home setting.1.4.2 Discharge planning1.4.2.1 Patients with heart failure should generally be discharged GPP from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account patient and carer wishes, and the level of care and support that can be provided in the community. NICE Guideline – Chronic heart failure 19
  22. 22. 1.4.2.2 The primary care team, patient and carer must be aware of GPP the management plan. 1.4.2.3 Clear instructions should be given as to how the GPP patient/carer can access advice particularly in the high-risk period immediately following discharge. 1.4.3 Multidisciplinary team approach to heart failure management 1.4.3.1 Heart failure care should be delivered by a multidisciplinary A team with an integrated approach across the healthcare community. 1.4.4 Non-NHS agencies 1.4.4.1 Standard One of The Older People NSF states: GPP Social care services will not use age in their eligibility criteria or policies to restrict access to available services. This applies to patients with heart failure. (See www.doh.gov.uk/nsf/olderpeople.htm) 1.4.4.2 Management plans for patients with heart failure should be GPP discussed with non-NHS agencies where they are involved in or responsible for the care of a person with heart failure. 1.4.4.3 The principles of pharmacological management for a patient GPP cared for in a non-NHS institution should be similar to those for any other patient with heart failure. 1.4.4.4 The education needs of non-NHS agency carers should be GPP considered. 1.5 Supporting patients and carers Understanding the information needs of patients and carers is vital. Key issues identified by patient focus groups include the importance of honesty and accurate information, and the potential value of support groups. The recommendations below are based on earlier consensus guidelines produced by a Royal College of Physicians’ working party. 1.5.1 Communication 1.5.1.1 Good communication between healthcare professionals and GPP patients and carers is essential for the best management of heart failure.20 NICE Guideline – Chronic heart failure
  23. 23. 1.5.1.2 Guidelines for good communication. C • Listen to patients and respect their views and beliefs. • Give patients the information they ask for or need about their condition, its treatment and prognosis, in a way they can understand, including information about any serious side effects of drugs to be prescribed. • Provide the most important information first. • Explain how each item will affect patients personally. • Present information in separate categories. • Make advice specific, detailed and concrete. • Use words the patients will understand; confirm understanding by questions; define unfamiliar words; write down key words; draw diagrams and keep a copy in the medical notes. • Repeat the information using the same words each time. • Prepare material, written or taped, to back up handwritten notes. • Share information with patients partners, close relatives or carers if they ask you to do so. When patients cannot indicate their consent for such sharing of information, it is advisable to share the information that those close to the patient need or want to know, except where you have reason to believe that the patient would object if able to do so.1.5.1.3 The content, style and timing of information provision should C be tailored to the needs of the individual patient.1.5.1.4 Healthcare professionals should assess cognitive ability when GPP sharing information.1.5.1.5 Carers and relatives of patients who are cognitively impaired GPP should be made aware of treatment regimens for the patients they care for and be encouraged to identify any need for clinical support.1.5.1.6 Management of heart failure should be seen as a shared GPP responsibility between patient and healthcare professional.1.5.1.7 Unless specifically excluded by the patient, carers and relatives GPP should be involved in the management of the patient, particularly where the patient cannot look after him- or herself.1.5.2 Prognosis1.5.2.1 Prognosis should be discussed with patients and carers in a GPP sensitive, open and honest manner. NICE Guideline – Chronic heart failure 21
  24. 24. 1.5.3 Support groups 1.5.3.1 Healthcare professionals should be aware of local cardiac GPP support networks and provide this information to patients and carers. 1.6 Anxiety and depression Depression tends to be more common in patients with heart failure than in the general population. Drug therapy with antidepressants may lead to complications such as fluid retention, hypotension and arrhythmias. 1.6.1.1 The diagnosis of depression should be considered in all C patients with heart failure. 1.6.1.2 Where depression is likely to have been precipitated by heart C failure symptoms then reassessment of psychological status should be undertaken once the physical condition has stabilised following treatment for heart failure. If the symptoms have improved no further specific treatment for depression is required. 1.6.1.3 Where it is apparent that depression is co-existing with heart C failure, then the patient should be treated for depression following the NICE guideline (Depression: the management of depression in primary and secondary care), scheduled for publication in February 2004. 1.6.1.4 For patients with heart failure, the potential risks and GPP benefits of drug therapies for depression should be considered carefully. 1.6.1.5 Patients with heart failure should consult a healthcare GPP professional before using over-the-counter therapies for depression such as St John’s wort (Hypericum perforatum). Healthcare professionals should be aware of the potential interaction with prescribed medication, and always ask about self-medication, including the use of herbal products. 1.7 End of life issues There is substantial evidence for considerable unmet palliative needs GPP of patients with heart failure and their informal carers. The main areas of need include symptom control, psychological and social support, planning for the future, and end of life care.22 NICE Guideline – Chronic heart failure
  25. 25. 1.7.1.1 Issues of sudden death and living with uncertainty are GPP pertinent to all patients with heart failure. The opportunity to discuss these issues should be available at all stages of care.1.7.1.2 The palliative needs of patients and carers should be GPP identified, assessed and managed at the earliest opportunity.1.7.1.3 Patients with heart failure and their carers should have GPP access to professionals with palliative care skills within the heart failure team.2 Notes on the scope of the guidanceAll NICE guidelines are developed in accordance with a scopedocument that defines what the guideline will and will not cover. Thescope of this guideline was established at the start of thedevelopment of this guideline, following a period of consultation; itis available from: www.nice.org.uk/docref.asp?d=22427The guideline covers the care provided by primary and secondaryhealthcare professionals who have direct contact with, and makedecisions concerning, the care of patients with heart failure. It alsoaddresses issues concerning the interface between primary andsecondary care, including in what circumstances patients should bereferred to or admitted to secondary care.The guideline addresses all the key areas of managing chronic heartfailure, including diagnosis, and pharmacological and non-pharmacological treatments.This guideline does not include specific reference to ‘acute’ heartfailure, but does include comment on exacerbation of the syndromeand the causes and treatment of this, recognising that chronic heartfailure often has an undulating course. It does not address thescreening or diagnosis of people who are asymptomatic, themanagement of patients with right heart failure as a consequence ofrespiratory disease, or post-transplant care. In addition, the guidelinedoes not cover the organisational aspects of heart failuremanagement. It does not therefore address models of care, the rolesor composition of primary or secondary healthcare teams andcompetencies, skill mix or training requirements.This guideline was developed for the NHS, and although it commentson the interface with other sectors, it does not consider them indetail. NICE Guideline – Chronic heart failure 23
  26. 26. 3 Implementation in the NHS 3.1 In general Local health communities should review their existing service provision for the management of heart failure against this guideline as they develop their Local Delivery Plans. The review should consider the resources required to implement fully the recommendations set out in Section 1 of this guideline, the people and processes involved, and the timeline over which full implementation is envisaged. It is in the interests of patients that the implementation timeline is as rapid as possible. Relevant local clinical guidelines and protocols should be reviewed in the light of this guidance and revised accordingly. 3.2 Audit Suggested audit criteria are listed in Appendix E. 4 Research recommendations Research recommendations have been identified during the development of this guideline. They are detailed in the full guideline (see Section 5). 5 Full guideline The National Institute for Clinical Excellence commissioned the development of this guidance from the National Collaborating Centre for Chronic Conditions. The Centre established a Guideline Development Group (see Appendix B), which reviewed the evidence and developed the recommendations. The full guideline, Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care, is published by the National Collaborating Centre for Chronic Conditions; it is available on its website (www.rcplondon.ac.uk/college/ceeu/ ncccc_index.htm), the NICE website (www.nice.org.uk) and on the website of the National Electronic Library for Health (www.nelh.nhs.uk).24 NICE Guideline – Chronic heart failure
  27. 27. The members of the Guideline Development Group are listed inAppendix B. Information about the Institute’s Guideline Review Panelis given in Appendix C.The booklet The Guideline Development Process – Information forthe Public and the NHS has more information about the Institute’sguideline development process. It is available from the Institute’swebsite and copies can also be ordered by telephoning0870 1555 455 (quote reference N0038).6 Related NICE guidanceNational Institute for Clinical Excellence (2000). Guidance on the useof implantable cardioverter defibrillators for arrhythmias. NICETechnology Appraisal Guidance No. 11. London: National Institute forClinical Excellence. Available from:www.nice.org.uk/Docref.asp?d=102397 Review dateThe process of reviewing the evidence is expected to begin 4 yearsafter the date of issue of this guideline (July 2007). Reviewing maybegin earlier than 4 years if significant evidence that affects theguideline recommendations is identified sooner. The updatedguideline will be available within 2 years of the start of the reviewprocess. A version of this guideline for patients with heart failure, their carers and the public is available from the NICE website (www.nice.org.uk) or from NHS Response Line (0870 1555 455; quote reference number N0248 for an English version and N0249 for an English and Welsh version) NICE Guideline – Chronic heart failure 25
  28. 28. Appendix A: Grading scheme The grading scheme and hierarchy of evidence used in this guideline are shown in the table below. Hierarchy of evidence Typical grading of recommendations Level Type of evidence Grade Evidence Ia Evidence obtained from A At least one randomised systematic review of meta- controlled trial as part of a analysis of randomised body of literature of overall controlled trials good quality and consistency addressing the specific Ib Evidence obtained from at least recommendation one randomised controlled trial (evidence levels Ia and Ib) IIa Evidence obtained from at least one well-designed B Well-conducted clinical controlled study without studies but no randomised randomisation clinical trials on the topic of recommendation (evidence IIb Evidence obtained from at least levels IIa, IIb, III) one other type of well-designed quasi-experimental study III Evidence obtained from well- designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies IV Evidence obtained from expert C Expert committee reports or committee reports or opinions opinions and/or clinical and/or clinical experience of experience of respected respected authorities authorities. This grading indicates that directly applicable clinical studies or good quality are absent (evidence level IV) GPP Recommended good practice based on the clinical experience of the Guideline Development Group DS Evidence from diagnostic DS Evidence from diagnostic studies studies NICE Evidence from NICE guidelines NICE Evidence from NICE guidelines or health technology appraisal or health technology appraisal programme programme Adapted from: National Institute for Clinical Excellence (2001). The Guideline Development Process – Information for National Collaborating Centres and Guideline Development Groups. London: National Institute for Clinical Excellence. Available from www.nice.org.uk.26 NICE Guideline – Chronic heart failure
  29. 29. Appendix B: The Guideline Development GroupMs Audrey AlimoNurse Consultant for Heart Failure, Central Middlesex Hospital,LondonDr Graham ArchardGeneral Practitioner, ChristchurchMr Steven BarnesHealth Services Research Fellow in Guideline Development, NationalCollaborating Centre for Chronic ConditionsProfessor Martin Cowie (Clinical Advisor)Professor of Cardiology, National Heart and Lung Institute, ImperialCollege, LondonMs Stephanie CruickshankHeart failure patient and carer representative; Cardiomyopathy NurseSpecialist, St George’s Hospital, LondonDr Perry ElliottSenior Lecturer in Cardiology, St George’s Hospital Medical School,LondonProfessor Rose Anne KennyProfessor of Geriatric Medicine, University of NewcastleDr Jonathan Mant (Lead)Senior Lecturer in Public Health, University of BirminghamMr Derrick MastersHeart failure patient and carer representativeDr Jennifer RobertsSenior Lecturer in Health Economics, School of Health and RelatedResearch, University of SheffieldProfessor Mojgan SaniConsultant Pharmacist, Guys’ and St Thomas’ Hospital Trust andVisiting Professor, School of Pharmacy and Pharmacology, Universityof BathMs Hasina ShaikhInformation scientist, National Collaborating Centre for ChronicConditions NICE Guideline – Chronic heart failure 27
  30. 30. Dr Lip-Bun Tan Consultant Cardiologist, Leeds General Infirmary Dr Ann Taylor Chartered Physiotherapist, School of Biomedical Sciences, King’s College London; Research Officer, Association of Chartered Physiotherapists in Cardiac Rehabilitation Ms Sarah Williams Project manager, National Collaborating Centre for Chronic Conditions Consensus reference group (CRG) To support the development of this guideline, a Consensus Reference Group (CRG) was formed. The CRG met early in the development process to ensure that the aims and the clinical questions addressed by the guideline were appropriate. The CRG met again at the end of the process to review the recommendations drafted by the Guideline Development Group. The group used formal consensus techniques in their consideration of clinically important areas where there was insufficient evidence or disagreement over the interpretation of the evidence. Professor John Camm (Chair) President, British Cardiac Society; Professor of Cardiology, St George’s Hospital Medical School, London Professor John Cleland Professor of Academic Cardiology, University of Hull Dr Michael Gammage Consultant Physician in Cardiovascular Medicine, Queen Elizabeth Hospital, Birmingham Dr Louise Gibbs* Consultant Physician in Palliative Care, St Christopher’s Hospice, Surrey Professor Richard Hobbs Professor of General Practice, University of Birmingham Ms Lee Hooper Research Associate in Evidence-Based Care and Systematic Review, University Dental Hospital of Manchester Dr Malcolm Metcalfe Consultant Cardiologist, Aberdeen Royal Infirmary28 NICE Guideline – Chronic heart failure
  31. 31. Ms Chris MonacoCardiology Department, Calderdale Royal HospitalDr Kevin OShaughnessy*University Lecturer in Clinical Pharmacology & Honorary ConsultantPhysician, Addenbrooke’s Hospital, CambridgeDr Chakravarthi Rajkumar*Senior Lecturer and Consultant Physician, Care of the Elderly, ImperialCollege School of Medicine, LondonMs Sara RichardsChair, Royal College of Nursing Practice Nurses’ Association; NursePractitioner, Slough NHS Walk-In CentreProfessor Jonathan Richards*External Professor of Primary Care, University of GlamorganDr David RobertsConsultant Cardiologist, Victoria Hospital, BlackpoolDr Chris Spencer-JonesDirector of Public Health, Dudley Health Authority* Attended and contributed to at least one GDG meeting NICE Guideline – Chronic heart failure 29
  32. 32. Appendix C: The Guideline Review Panel The Guideline Review Panel is an independent panel that oversees the development of the guideline and takes responsibility for monitoring its quality. The Panels include experts on guideline methodology, health professionals and people with experience of the issues affecting patients and carers. The members of the Guideline Review Panel for this guideline were as follows. Dr Bernard Higgins (Chair) Consultant Chest Physician Freeman Hospital Newcastle upon Tyne Dr Robert Higgins Consultant in Renal and General Medicine University Hospitals Coventry and Warwickshire Dr Marcia Kelson Director Patient Involvement Unit for NICE College of Health London Dr Peter Rutherford Senior Lecturer in Nephrology, Medical Director University College of Wales College of Medicine Dame Helena Shovelton Chief Executive British Lung Foundation Fiona Wise Acting Director of Modernisation Bedfordshire and Hertfordshire Strategic Health Authority Dr John Young Medical Director Merck Sharp and Dohme30 NICE Guideline – Chronic heart failure
  33. 33. Appendix D: Further information on pharmacologicaltreatmentTable A Diuretics (oral): dosages and side effectsDrug Initial dose (mg) Maximum recommended daily dose (mg)Loop diureticsBumetanide 0·5–1·0 5–10Furosemide 20–40 250–500Torasemide 5–10 100–200Thiazides*Bendroflumethiazide 2.5 5 (previously called bendrofluazide)Indapamide 2·5 2·5Metolazone 2·5 10Potassium-sparing diuretics +ACEI –ACEI +ACEI –ACEIAmiloride 2·5 5 20 40Triamterene 25 50 100 200For spironolactone, see page 9ACEI, angiotensin converting enzyme inhibitor*May be effective when added to loop diuretics when fluid retention is resistant, but canpromote dramatic diuresis and disturbance in fluid balance and electrolytes. Patient mustbe closely monitored and specialist advice is required NICE Guideline – Chronic heart failure 31
  34. 34. Table B Practical recommendations on the use of ACE inhibitors Which ACE inhibitor and what dose? Licensed ACEI Starting dose (mg) Target dose (mg) Captopril 6.25 three times daily 50–100 three times daily Cilazapril* 0.5 once daily 1–2.5 once daily Enalapril 2.5 twice daily 10–20 twice daily Fosinopril* 10 once daily 40 once daily Lisinopril 2.5–5.0 once daily 30–35 once daily Perindopril* 2.0 once daily 4 once daily Quinapril* 2.5–5.0 once daily 10–20 once daily Ramipril 2.5 once daily 5 twice daily or 10 once daily *Target dose based on manufacturer’s recommendation rather than large outcome study How to use • Start with a low dose (see above) • Seek specialist advice where the patient is on a high dose (e.g. furosemide 80 mg) of a loop diuretic • Double dose at not less than 2 weekly intervals • Aim for target dose (see above) or, failing that, the highest tolerated dose • Remember some ACE inhibitor is better than no ACE inhibitor • Monitor blood electrolytes (in particular potassium), urea, creatinine, and blood pressure • When to stop up-titration/down-titration – see ‘Problem solving’ Advice to patient • Explain expected benefits • Treatment is given to improve symptoms, to prevent worsening of heart failure and to increase survival • Symptoms improve within a few weeks to a few months • Advise patients to report principal adverse effects (i.e. dizziness/symptomatic hypotension, cough) Problem solving • Asymptomatic low blood pressure does not usually require any change in therapy Symptomatic hypotension • If dizziness, light-headedness and/or confusion and a low blood pressure consider discontinuing nitrates, calcium channel blockers* and other vasodilators • If no signs/symptoms of congestion consider reducing diuretic dose • If these measures do not solve problem seek specialist advice *Calcium channel blockers should be discontinued unless absolutely essential (e.g. for angina or hypertension). Continued32 NICE Guideline – Chronic heart failure
  35. 35. Which ACE inhibitor and what dose? ContinuedCough• Cough is common in patients with chronic heart failure, many of whom have smoking-related lung disease• Cough is also a symptom of pulmonary oedema which should be excluded when a new or worsening cough develops• ACE inhibitor induced cough rarely requires treatment discontinuation• If the patient develops a troublesome dry cough which interferes with sleep and is likely to be caused by an ACE inhibitor, consider substituting an angiotensin II receptor antagonist for the ACE inhibitorWorsening renal function• Some rise in urea, creatinine and K+ is to be expected after initiation of an ACE inhibitor; if the increase is small and asymptomatic no action is necessary• An increase in creatinine of up to 50% above baseline, or to 200 µmol/litre, which ever is the smaller, is acceptable• An increase in K+ to ≤ 5.9 mmol/litre is acceptable• If urea, creatinine or K+ do rise excessively consider stopping concomitant nephrotoxic drugs (e.g. NSAIDs), non-essential vasodilators (e.g. calcium antagonists, nitrates), K+ supplements/retaining agents (triamterene, amiloride) and, if no signs of congestion, reducing the dose of diuretic• If greater rises in creatinine or K+ than those outlined above persist despite adjustment of concomitant medications the dose of the ACE inhibitor should be halved and blood chemistry rechecked, if there is still an unsatisfactory response specialist advice should be sought• If K+ rises to ≥ 6.0 mmol/litre or creatinine increases by > 100% or to above 350 µmol/litre the dose of ACE inhibitor should be stopped and specialist advice sought• Blood electrolytes should be monitored closely until K+ and creatinine concentrations are stableNote: it is very rarely necessary to stop an ACE inhibitor and clinical deteriorationis likely if treatment is withdrawn; ideally, specialist advice should be soughtbefore treatment discontinuationAdapted from European Journal of Heart Failure 2001, 3, 495-502 (McMurray et al.Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactonein heart failure: putting guidelines into practice), copyright (2001), with permission fromEuropean Society of Cardiology. NICE Guideline – Chronic heart failure 33
  36. 36. Table C Practical recommendations on the use of beta-blockers Which beta-blocker and what dose? Which beta-blocker and what dose? Only two beta-blockers are licensed for the treatment of heart failure in the UK at the time of issue of this guideline. Starting dose (mg) Target dose (mg) Bisoprolol 1.25 once daily 10 once daily Carvedilol 3.125 twice daily 25–50 twice daily* * Carvedilol: maximum dose 25 mg twice daily if severe heart failure. For patients with mild to moderate heart failure maximum dose 50 mg twice daily if weight more than 85 kg – otherwise maximum dose 25 mg twice daily How to use • Start with a low dose (see above) • Double dose at not less than 2 weekly intervals • Aim for target dose (see above) or, failing that, the highest tolerated dose • Remember some beta-blocker is better than no beta-blocker • Monitor heart rate, blood pressure, clinical status (symptoms, signs, especially signs of congestion, body weight) • Check blood electrolytes, urea and creatinine 1–2 weeks after initiation and 1–2 weeks after final dose titration • When to down-titrate/stop up-titration, see ’Problem solving’ Advice to patient • Explain expected benefits • Emphasise that treatment given as much to prevent worsening of heart failure as to improve symptoms; beta-blockers also increase survival • If symptomatic improvement occurs, this may develop slowly (3–6 months or longer) • Temporary symptomatic deterioration may occur (estimated 20–30% of cases) during initiation/up-titration phase • Advise patient to report deterioration (see ’Problem solving’) and that deterioration (tiredness, fatigue, breathlessness) can usually be easily managed by adjustment of other medication; patients should be advised not to stop beta-blocker therapy without consulting their physician • Patients should be encouraged to weigh themselves daily (after waking, before dressing, after voiding, before eating) and to consult their doctor if they have persistent weight gain Problem solving Worsening symptoms/signs (e.g. increasing dyspnoea, fatigue, oedema, weight gain) • If increasing congestion, double dose of diuretic and/or halve dose of beta- blocker (if increasing diuretic does not work) • If marked fatigue (and/or bradycardia, see below) halve dose of beta-blocker (rarely necessary) • Review patient in 1–2 weeks; if not improved seek specialist advice • If serious deterioration, halve dose of beta-blocker or stop this treatment (rarely necessary); seek specialist advice Continued34 NICE Guideline – Chronic heart failure
  37. 37. Which beta-blocker and what dose? ContinuedLow heart rate• If < 50 beats/min and worsening symptoms – halve dose beta-blocker or, if severe deterioration, stop beta-blocker (rarely necessary)• Consider need to continue treatment with other drugs that slow the heart (e.g. digoxin, amiodarone, diltiazem) and discontinue if possible• Arrange ECG to exclude heart block• Seek specialist adviceAsymptomatic low blood pressure• Does not usually require any change in therapySymptomatic hypotension• If low blood pressure causes dizziness, light-headedness or confusion, consider discontinuing drugs such as nitrates, calcium channel blockers and other vasodilators• If no signs/symptoms of congestion consider reducing diuretic dose• If these measures do not solve problem seek specialist adviceNote: beta-blockers should not be stopped suddenly unless absolutely necessary(there is a risk of a ‘rebound’ increase in myocardial ischaemia/infarction andarrhythmias); ideally specialist advice should be sought before treatmentdiscontinuationAdapted from European Journal of Heart Failure 2001, 3, 495-502 (McMurray et al.Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactonein heart failure: putting guidelines into practice), copyright (2001), with permission fromEuropean Society of Cardiology. NICE Guideline – Chronic heart failure 35
  38. 38. Table D Practical recommendations for the use of spironolactone Which dose of spironolactone? Dose (mg) 12.5–25 daily * * 50 mg may be advised by a specialist if heart failure deteriorates and no problem with hyperkalaemia How to use • Start at 25 mg once daily • Check blood chemistry at: 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6 monthly thereafter • If K+ rises to between 5.5 and 5.9 mmol/litre or creatinine rises to 200 µmol/litre reduce dose to 25 mg on alternate days and monitor blood chemistry closely • If K+ rises to ≥ 6.0 mmol/litre or creatinine to > 200 µmol/litre stop spironolactone and seek specialist advice Advice to patient • Explain expected benefits • Treatment is given to improve symptoms, prevent worsening of heart failure and to increase survival • Symptom improvement occurs within a few weeks to a few months of starting treatment • Avoid NSAIDs not prescribed by a physician (self-purchased ‘over the counter’ treatment, e.g. ibuprofen) • Temporarily stop spironolactone if diarrhoea and/or vomiting and contact physician Problem solving Worsening renal function/hyperkalaemia: • See ’How to use’ • Major concern is hyperkalaemia (≥ 6.0 mmol/litre) though this was uncommon in the RALES clinical trial; a potassium level at the higher end of the normal range may be desirable in patients with heart failure, particularly if taking digoxin • Some ‘low salt’ substitutes have a high K+ content • Male patients may develop breast discomfort and/or gynaecomastia Adapted from European Journal of Heart Failure 2001, 3, 495-502 (McMurray et al. Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice), copyright (2001), with permission from European Society of Cardiology.36 NICE Guideline – Chronic heart failure
  39. 39. Table E Currently available angiotensin II receptor antagonistsDrug* Daily dose (mg)Candesartan 4–16Eprosartan 400–800Irbesartan 150–300Losartan 50–100Telmisartan 40–80Valsartan 80–320*None of these drugs is currently licensed for the treatment of heart failure in the UKTable F Major co-morbidities that impact on the management ofheart failureCo-morbidity CommentsCOPD/asthma/ Beta-blockers are contraindicated in patients withreversible airways reversible airways disease. The British Nationaldisease Formulary (45th edition, 2003) states ‘Beta-blockers should be avoided in patients with a history of asthma or chronic obstructive airways disease; if there is no alternative, a cardioselective beta-blocker may be used with extreme caution under specialist supervision’.Renal dysfunction ACE inhibitors and angiotensin-II receptor antagonists(e.g. serum creatinine may be contraindicated. Patient requires specialist> 200 µmol/litre) assessment.Anaemia Anaemia is common in patients with moderate to severe heart failure and where due to the heart failure (and not other causes) treatment with erythropoeitin and iron therapy may improve symptoms and reduce the risk of hospitalisation for worsening heart failure. The results of several large RCTs addressing this issue are awaited.Thyroid disease Severe thyroid dysfunction may cause or precipitate heart failure.Peripheral vascular Not an absolute contraindication to beta-blocker therapy.disease High index of suspicion for renal artery stenosis required.Urinary frequency Requires appropriate specialist referral. Alpha-blockers may cause hypotension or fluid retention, but are not absolutely contraindicated in patients with heart failure. Diuretics likely to be less well tolerated.Gout Avoid non-steroidal anti-inflammatory drugs. Gout can be exacerbated by diuretics and may have an atypical presentation in patients with heart failure. Colchicine may be useful for the treatment of an acute attack of gout. Allopurinol may be useful at reducing the risk of further attacks of gout, but should not be started at the time of an acute episode of gout. NICE Guideline – Chronic heart failure 37
  40. 40. 38 Appendix E: Technical detail on the criteria for audit Key recommendations Denominator Other relevant Exceptions Definition of terms recommendations 1.1.3.1: 1. ‘Disease register’ Where the diagnosis of Patient choice; or where The diagnostic algorithm The basis for historical heart failure is still this would be (see page 5) summarises diagnoses of heart failure % of patients on general suspected, but inappropriate (e.g. how a diagnosis of heart should be reviewed, and practice heart failure confirmation of the terminal illness) failure should be only patients whose registers who have had underlying cardiac confirmed. diagnosis is confirmed this diagnosis confirmed. abnormality has notNICE Guideline – Chronic heart failure should be managed in occurred then the patient accordance with this should have appropriate guideline further investigation. 1.1.1.5: 2. Echocardiography – Patient choice; patient – Transthoracic Doppler 2D declining further echocardiographic % of patients with a new investigation, or where examination should be diagnosis of heart failure this would be performed to exclude (in the previous 12 inappropriate (e.g. important valve disease, months) who have had an terminal illness) assess the systolic (and echocardiogram diastolic) function of the (left) ventricle and detect intracardiac shunts 1.2.2.2: 3. ACE inhibitors At the time of issue of this Patient choice; – All patients with heart guideline, angiotensin II contraindications (see failure due to left % of patients with heart receptor antagonists are guideline text); or ventricular systolic failure due to left not licensed in the UK for documented adverse dysfunction should be ventricular systolic heart failure and studies events led to withdrawal considered for treatment dysfunction who are are ongoing. However, of ACE inhibitor; heart with an ACE inhibitor prescribed an ACE they may provide an failure not due to left inhibitor or an angiotensin alternative to ACE ventricular systolic II receptor antagonist, if inhibitors for patients dysfunction. ACE inhibitors are contra- intolerant of ACE indicated inhibitors (for example, because of cough).
  41. 41. Key recommendations Denominator Other relevant Exceptions Definition of terms recommendations 1.2.2.6: 4. Beta-blockers Patients who develop Patient choice; – Beta-blockers licensed for heart failure due to left contraindications (see use in heart failure should % of patients with heart ventricular systolic guideline text); or be initiated in patients failure due to left dysfunction and who are documented adverse with heart failure due to ventricular systolic already on treatment with events led to withdrawal left ventricular systolic dysfunction who are a beta-blocker for a of beta-blocker; heart dysfunction after diuretic prescribed a beta-blocker concomitant condition failure not due to left and ACE inhibitor therapy should continue with a ventricular systolic (regardless of whether or beta-blocker – either their dysfunction. not symptoms persist) current beta-blocker or an alternative licensed for heart failure treatment. 1.3.1.1: 5. Monitoring The frequency of Patient choice – All patients with chronic monitoring should depend heart failure require Percentage of patients on the clinical status and monitoring. This with proven heart failure stability of the patient. monitoring should include: who are reviewed on a Monitoring interval should • A clinical assessment of 6-monthly* basis be short (days to weeks) if functional capacity, * this is a minimum the clinical condition or fluid status, cardiac medication has changed, rhythm, and cognitive but is required at least 6 and nutritional status monthly for stable • A review of medication, patients with proven heart including need for failure changes and possible side effects • Serum urea, electrolytes and creatinineNICE Guideline – Chronic heart failure39

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